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Coverage criteria policies

Blepharoplasty, blepharoptosis repair, and brow lift

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for blepharoplasty, blepharoptosis repair and brow lift.

Prior authorization is not required for entropion and ectropion repair

Coverage

Blepharoplasty, blepharoptosis repair and brow lift is not covered for cosmetic reasons to improve the appearance of the patient, but may be covered subject to the indications listed below and per your plan documents. Each eye, and/or eye procedure, will be evaluated separately for coverage.

Entropion and ectropion repair are not related to blepharoplasty / ptosis repair and are generally covered subject to the indications listed below and per your plan documents.

The following must be submitted when requesting blepharoplasty, blepharoptosis repair and brow lift.

  1. Eye exam with chief complaint, HPI and diagnosis
  2. Color photographs
  3. Peripheral or superior visual fields, Goldman or automated, reliable, untapped/taped. Manual visual field testing will be accepted in situations where computerized visual field testing is not available

Indications that are covered

Blepharoplasty

Blepharoplasty is covered when all of the following criteria are met:

  1. Color photographs must be included and show:
    1. The eyelid at or below the upper edge of the pupil; or
    2. Excess skin (dermatochalasis/blepharochalasis) above the eye touches or is resting on the eyelashes
  2. Written documentation of diagnosis and description of the functional/physical impairment directly related to an abnormality of the eyelids(s); and
  3. Documentation of a visual field testing with the eyelids or brow taped and untaped, showing improvement of at least 12 degrees or 30 percent or more in number of points seen.
  4. Written documentation of the provider’s interpretation of the visual field testing
  5. Repair of the eyelids related to prosthesis difficulties in an anophthalmic socket is covered.
  6. Surgical repair/intervention of the following conditions is covered:
    1. Defect caused by trauma or tumor – ablative surgery (e.g., entropion corneal exposure)
    2. Periorbital sequelae of thyroid disease and nerve palsy
    3. Painful symptoms of blepharospasm
    4. Chronic eyelid dermatitis due to redundant skin refractory to medical therapy

Blepharoptosis repair

Blepharoptosis repair is covered when all the following criteria are met:

  1. A MRD (marginal reflex distance) measurement of less than or equal to 2.0 mm
  2. Written documentation in the medical records indicates all of the following
    1. A frontal, straight –ahead photograph showing the abnormal lid droop//displacement
    2. Diagnosis and description of functional impairment that relates to the need for blepharoptosis repair
  3. Congenital ptosis with supportive documentation of a risk of amblyopia is covered.

Brow lift

Note: Brow lift is generally considered cosmetic

A brow lift is covered when all the following criteria are met:

  1. Visual impairment caused by brow malposition as indicated by eyebrows at the level of the top of the eyelashes
  2. Written documentation in the medical records indicates all of the following
    1. Documentation states why the functional visual impairment cannot be corrected by blepharoplasty or blepharoptosis alone
    2. Diagnosis and description of functional impairment that relates to the need for a brow lift
    3. A frontal, straight-ahead photograph showing that the eyebrows are at the level of the top of the eyelashes

Indications that are not covered

  1. Lower lid blepharoplasty is considered cosmetic and is generally not covered.
  2. Blepharoplasty, blepharoptosis repair and brow lift surgery to improve the appearance when no functional impairment exists is considered cosmetic and is excluded from coverage.
  3. Blepharoplasty, blepharoptosis repair and brow lift when there are medical conditions present that will make it unlikely that a blepharoplasty will correct the visual field including but not limited to Sjogren’s syndrome, Graves’ disease, polymyositis and myasthenia gravis.

Definitions

Blepharochalasis is relaxation of the upper eyelid skin, usually due to a history of lid edema/swelling.

Blepharoplasty is a procedure involving he surgical removal of redundant skin, muscle and fatty tissue from the eyelids for the purpose of improving abnormal function (e.g., repair excess tissue that obstructs the visual filed), reconstructive deformities or enhancing the appearance.

Blepharoptosis is a drooping or displacement of one or both upper eyelids due to a weak levator mechanism.

Brow lift involves the excision of excess forehead or anterior scalp skin. Redundancy and ptosis of the skin of the lateral forehead and eyebrows may aggravate hooding of the lateral upper eyelids. This is an exaggerated effect of aging. Correction of upper lateral visual field loss, when associated with hooding of the lateral eyelid skin caused by ptosis of the brow may not provide satisfactory results. In these cases, a brow lift may be indicated to suspend the brows in a more normal position and relieve the ptosis and visual obstruction.

Brow ptosis is the laxity of the forehead muscles and sagging tissue of the eyebrows and/or forehead

Dermatochalasis is the redundancy of upper eyelid skin

Ectropion means the eversion or turning outward of the eyelid margin away from the eyeball. Common with aging this condition can lead to chronic irritation of the palpebral (lower eye lid) conjunctiva and/or interfere with the normal tear drainage process, causing excessive tearing.

Entropion means the inversion or turning inward of the eye lid margin and eye lashes against the eyeball.

Functional/Physical Impairment: a physical/functional or physiological impairment causes deviation from the normal function of a tissue or organ. This results in a significantly limited, impaired or delayed capacity to move, coordinate actions or perform physical activities and is exhibited by difficulties in one or more of the following areas: physical and motor tasks; independent movement; performing basic life functions

Marginal Reflex Distance (MRD) is a measurement that assess the distance from the apparent center (visual axis) of the pupil to the upper lid. MRD measures the number of millimeters from the corneal light reflex or center of the pupil to the upper lid margin

Mechanical ptosis, or Pseudoptosis, refers to a condition in which the eyelid skin is redundant and weighs the lid down creating a ptotic-like condition.

Ptosis is drooping of the upper eyelids that cause the margin to rest at a position lower than normal. Ptosis may be classified as either “true ptosis” (lack of eyelid support) or “pseudo ptosis” (presence of excess lid tissue).

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The services associated with these codes require prior authorization:

    Codes

    Description

    15820

    Blepharoplasty, lower eyelid

    15821

    Blepharoplasty, lower eyelid; with extensive herniated fat pad

    15822

    Blepharoplasty, upper eyelid

    15823

    Blepharoplasty, upper eyelid; with excessive skin weighting down lid

    67900

    Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)

    67901

    Repair of blepharoptosis; frontalis muscle technique with suture or other material (e.g., banked fascia)

    67902

    Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia)

    67903

    Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach

    67904

    Repair of blepharoptosis; (tarso) levator resection or advancement, external approach

    67906

    Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia)

    67908

    Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (e.g., Fasanella-Servat type)

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. American Society of Plastic Surgeons (ASPS). ASPS Recommended Insurance Coverage Criteria for Third-Party Payers: Blepharoplasty. http://www.plasticsurgery.org/Documents/medical-professionals/healthpolicy/insurance/ASPS-Recommended-Insurance-Coverage-Criteria-for-Blepharoplasty.pdf March 2007.
  2. Cahill, K. V., Bradley, E. A., Meyer, D. R., Custer, P. L., Holck, D. E., Marcet, M. M., & Mawn, L. A. (2011). Functional Indications for Upper Eyelid Blepharoptosis and Blepharoplasty Surgery. Ophthalmology, 118(12), 2510-2517. doi:10.1016/j.ophtha.2011.09.029
  3. Lee, MS. Overview of ptosis. In: Basow, DS (Ed). UpToDate. Waltham, MA: (February 15, 2017)
  4. Nemet AY. Accuracy of Marginal Reflex Distance Measurements in Eyelid Surgery. J Craniofac Surg. 2015 Oct; 26(7):e569-71

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Policy activity

  • 01/01/1994 - Date of origin
  • 12/01/2017 - Effective date
Review date
  • 12/2018
Revision date
  • 11/01/2017

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